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I have been fortunate to have only been climbing that last 10% for three years. I have pushed VA doctors to correct patient treatment notes in myhealthevet, been sure to explain my symptoms to them in rater's terms, and I've been relentless at using every test or procedure available through the VA to document the ailments and I still have three more claims to continue to fight on. I would encourage you to make a move up the mountain, especially if you are having conditions worsen as time goes on. The claims and appeals process has sped up, but just because the shade of lipstick became more appealing doesn't change the fact that it's an ugly pig wearing it. Getting denials sooner than before doesn't make you happy, but if we attack them with their own playbook, you increase your odds of catching them with their pants down. The claim that put me to 100% was a 30% migraines claim that I put in for an increase to 50%. Instead, they dropped me to 0%. But by doing some reading on here, scouring through my health records, and putting my VA doc on the spot with a DBQ in hand, I gave a reversal a shot in January and it just now paid off. @rootbeer22, I hope you give it another go and let us come along for the ride

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any updates my friend?

Yeah, this sounds like textbook "Treatment Emergent CSA". It's supposed to eventually go away in OSA cases after continued use with the CPAP, so if it dropped your amount of obstructives to be lower than the amount of centrals, that is proof positive that it is necessary. On my original sleep study with no PAP titration, I had 6 obstructive apneas, 19 central apneas, 2 mixed apneas and 31 hypopneas. Because of the inability to distinguish a "central hypopnea", they label them as obstructive and boom, I was labeled OSA. In my case though, the sleep doc noted that the amount of central apneas was abnormal and my obstructive apneas disappeared with my BiPAP ASV, while centrals lowered but were still persistent (AHI of 3.5 avg). Therefore, she deemed it "more likely than not TBI related CSA". I believe this is the KEY for 50%. A word of caution on the word "recommended" though because I feel like it isn't strong enough. "Required" or the other words mentioned would be more definitive and not leave much wiggle room. However....PAP treatment may still end up being listed as an option because there are "mouth guards" that could be used for OSA. I have an extremely sensitive gag reflex and couldn't even stand a mouth guard in sports, so that was a no go for me. Not sure if a mouth guard would be effective for your situation, but if it isn't make sure the doctor notes it or try to find literature that suggests why it was not chosen for treatment. I do not believe the mouth guard counts for the 50%, but I could very well be wrong. As far as the CPAP, I read that the VA classifies other positive airway pressure devices (AutoPAP, BiPAP, etc.) as equivalent to a CPAP. Despite my VSOs hesitation due to my recent 100% P&T, I'll likely be heading to the BVA on my denial because if this apnea were to make me kick the bucket, I want the service connection. I sincerely hope you don't have to do the same for your claim!